The pressure for EHR (Electronic Health Record) adoption is increasing, thanks to the incentives assured and warnings of reimbursement cuts. Though electronic clinical documentation is said to reduce the relevance and significance of medical transcription, the truth is that EHR has altered the process of transcription, particularly the role of medical transcriptionists (MTs). The most significant impact is the transition of MTs to editors. Let’s take a detailed look at how the role of MTs is changing with widespread adoption of EHR.
While transitioning to an EHR system comprised of point-and-click templates, physicians face several challenges. The templates make them slow down since they have to spend more time for documentation; they lose the quality in the narrative with pre-filled templates; and errors occur while copy-pasting notes. Medical transcriptionists usually flag errors such as wrong drug names, inconsistent findings, dosage and more for physicians to review during their job. Due to this editing step, the transcribed notes would have maximum accuracy when completed. So, even with an EHR system, busy physicians can benefit from the service of medical transcriptionists and ensure that the data within the system is accurate.
Transition to Editors – A Detailed View
EHRs have the ability to interface directly with transcription platforms to parse data. Static information snapshots or flat files that were created by transcription are now replaced with discrete data fields. Now, dictation software having advanced speech recognition capability is required to ensure greater efficiency in data transfer. With speech recognition system, there is no need for a typed document. As a result, medical transcriptionists now edit the medical documents instead of creating them. Since admission, transfer feeds, discharge and clinical dictation can be integrated between systems, patient demographic information can be systematically merged for editing, which also speeds up the turnaround times.
NLP (natural language processing) technology used at present has the capability of understanding spoken dictation and converting it into electronic text that can be parsed and mapped to particular data fields. NLP technology in combination with transcription management software helps providers to integrate dictation into the EHR, based on pre-defined templates that decide where the data should be entered within the electronic record. Professional transcriptionists serving multi-facility systems or outsourced transcription firms will find this system extremely useful. They need not spend time formatting clinical narratives to meet the specific requirements of each hospital. Since formatting is handled by the software, tangible benefits gained include faster turnaround time, excellent productivity and improved standardization.
The Changing Face of Medical Transcripiton
A survey conducted by the American Health Information Management Association and the Association for Healthcare Documentation Integrity in 2013 found that new speech and language processing technologies has led to a fundamental transformation in the way transcriptionists work and around 87 percent of respondents are preparing for new ways of doing things. The survey also revealed that the two major roles into which transcriptionists are transitioning are chart integrity auditor and EHR technician/HIM analyst whose role is to perform direct documentation into the EHR and auditing for accuracy and completeness.
On the whole, medical transcriptionists still play a significant role in medical record documentation. In the backdrop of widespread EHR adoption, the service of skilled transcriptionists will help practices ensure that their electronic health records are accurate. Practices should either give proper training to their transcriptionists to adapt to the advanced technology or obtain support from professional transcription companies that offer the service of transcriptionists skilled in EHR transcription for accurate and complete electronic documentation.